Provider Demographics
NPI:1205921202
Name:FOOTHILLS SPORTS MEDICINE & REHABILITATION- TUCSON, LLC
Entity type:Organization
Organization Name:FOOTHILLS SPORTS MEDICINE & REHABILITATION- TUCSON, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BASTEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:480-689-5515
Mailing Address - Street 1:15410 S MOUNTAIN PKWY STE 112
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-6691
Mailing Address - Country:US
Mailing Address - Phone:480-706-1161
Mailing Address - Fax:480-706-7997
Practice Address - Street 1:7575 W. TWIN PEAKS RD
Practice Address - Street 2:SUITE 155
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85743
Practice Address - Country:US
Practice Address - Phone:520-744-6445
Practice Address - Fax:520-742-5252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0460080OtherBCBS
AZAZ0460080OtherBCBS